Q: I realize that if the body mass index (BMI) of a patient is documented by nurses and dieticians, it can be coded if the physician documents the clinical significance (i.e., morbid obesity). However, if the BMI is documented by a patient care tech or nursing ward secretary in...Read More »
More than 1,000 CDI professionals now hold the Certified Clinical Documentation Specialist (CCDS) certification. ACDIS publishes the list of those who earned their certification on a quarterly basis. The latest list is available on the “...Read More »
Here is a statistic that will come as no surprise to most coders and CDI professionals: Approximately 50% of physicians, physician assistants, and nurse practitioners have no clue about ICD-10.Read More »
Q: The physician documented mild bronchitis treated with Zithromax in the progress note on day two of the patient’s hospital. I looked for clinical indicators and the only documentation I found in the nursing notes was that the patient had a non-productive cough on admission. ...Read More »
Go to your local bookstore, pick up a copy of Gray’s Anatomy (the book, not the television show), and flip though the illustrations. Alternately, you can Google “Gray’s anatomy illustrations.” They are in the public domain. Some of them are...Read More »
